4 Fractures of the Proximal Humerus 57 4 Fractures of the Proximal Humerus

M. Tile

4.1 Introduction

4.1.1 General Considerations

Fig. 4.1. Since the publication of the early editions of this The four major frag- ments of the proximal humerus. book, there has been considerable interest in the 1, Humeral head superior to the management of these fractures (Szyszkowitz et al. anatomical neck; 2, lesser tuberos- 1993, 1999; Rasmussen et al. 1992; Flatow et al. 1991; ity; 3, greater tuberosity; 4, shaft Robinson et al 2002), so we can no longer state that of the humerus fractures of the proximal humerus have for years been relegated to the surgical scrap heap. The major- supply is precarious. Therefore, if the head fragment ity of these fractures occur in elderly individuals, is displaced following injury, avascular necrosis may are stable, and can be successfully treated by judi- be the inevitable result. cious neglect. Unfortunately, the same reasoning, and The second fragment consists of the lesser tuber- therefore the same treatment, is too often applied to osity with its attached subscapularis muscle. Avulsion the minority which occur in young individuals, are of this fragment may allow undue external rotation of unstable, and have a poor prognosis. Operative tech- the head in the presence of a humeral neck fracture. niques have become more standardized and are more The third fragment is the greater tuberosity with often related to the type of fracture and the quality its attached rotator cuff. Isolated avulsions of this of the bone. The problem of surgical care in osteopo- fragment are equivalent to rotator cuff avulsions, rotic bone remains; however, many of the technical while those associated with a surgical neck fracture difficulties are being solved, by minimally invasive may allow internal rotation of the head fragment. techniques and by the new concept of the «Fixateur The fourth fragment is created by a fracture Interne.» By applying the same principles of treat- through the surgical neck of the humerus and is the ment to this particular fracture as to any other, a most common fracture in this area. As in other areas logical approach may be developed which will suit of metaphyseal bone, the behavior of this fragment all groups of patients. differs according to the type of injury, be it compres- sion, rendering the fracture stable, or shear, render- ing it unstable. Also, the presence of ample soft tissue 4.1.2 attachment to the large head fragment makes avascu- Anatomy lar necrosis most unlikely. These anatomical considerations are of major Codman (1934) recognized that fractures of the prox- clinical significance. Fractures of the upper end of imal humerus may separate into four major frag- the humerus may be compared to those of the upper ments (Fig. 4.1). The first fragment is the humeral femur. Fractures through the anatomical neck of the head, consisting of that portion of the humerus supe- humerus are akin to intracapsular fractures of the rior to the anatomical neck. Since this head fragment femur, i.e., they are intracapsular. The fractured frag- is almost completely covered by articular cartilage ments are almost entirely covered by articular carti- and is devoid of soft tissue attachment, its blood lage and are therefore devoid of a blood supply, lead-

4.1 Introduction

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ing to a high incidence of avascular necrosis for both from the anterior circumflex perfuses the humeral (Fig. 4.2a, b). Fractures through the surgical neck of head. Fractures of the head often have a small, wedge- the humerus are more akin to intertrochanteric and shaped portion of the metaphysis attached, which pertrochanteric fractures of the femur, i.e., they are may contain the arcuate artery and maintain the extracapsular, usually with an adequate blood supply viability of the humeral head (see Fig. 4.16a). The and a relatively low incidence of avascular necrosis importance of maintaining the soft tissue attach- (Fig. 4.2c,d). ment to this area cannot be overstated, as stressed by Szyszkowitz et al. (1993, 1999). Other blood supply enters through the rotator cuff or branches of the posterior humeral circumflex artery; neither can normally maintain viability to the humeral head.

4.1.4 Four-Segment Classification

Neer (1970) expanded the anatomical considerations ab of Codman into a working classification based on the displacement of the fragments. The group of minimally displaced fractures that may be treated by closed means must, in his opinion, have no seg- ment displaced more than 10 mm or angulated more than 45°. He further classified the displaced fractures according to the number of parts fractured, plus the presence of a dislocation. For example, the greater tuberosity fragment may be involved in a two-, three-, or four-part fracture, with or without a dislocation. Neer’s classification, based on a study of 300 cases, has clarified the natural history of these various c d types. Once it became evident that some types treated Fig. 4.2a–d. Comparison of the intracapsular anatomical neck by closed means were associated with dismal results, fracture of the humerus (a) with the intracapsular fracture of logical decision-making could follow. the neck of the femur (b). Both are almost entirely covered by articular cartilage and therefore devoid of blood supply, resulting in a high incidence of avascular necrosis for both. c,d 4.1.5 Comparison of the extracapsular surgical neck fracture of the humerus (c) with the intertrochanteric extracapsular fracture Stability of the proximal femur (d). Since they are extracapsular, the incidence of avascular necrosis is low In any classification, consideration should also be given to the stability of a given fracture, as well as to the number of segments involved. Cancellous 4.1.3 bone may fail in compression, resulting in a stable Vascular Anatomy impacted fracture or in tension or shear, resulting in an unstable fracture (Fig. 4.4). These two types of As in the femoral head, the blood supply to the injury behave quite differently. The stable impacted humeral head is precarious, because both are cov- types cause less pain, allowing earlier movement, and ered in articular cartilage. A precise knowledge of heal rapidly. In contrast, the unstable types cause the blood supply is essential to understanding the severe pain, precluding early function; in addition, outcome of some of the injury patterns and also to healing is often delayed. Therefore, to consider only avoid the distraction of any remaining blood to the the number of fracture segments irrespective of their humeral head during surgery. The main blood supply stability may lead to poor management decisions, to the humeral head is from the anterior humeral cir- usually toward overtreatment. An impacted, stable, cumflex artery (Fig. 4.3). The arcuate artery arising relatively painless fracture of the proximal humerus

4.1 Introduction

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osteoporotic bone, which greatly reduces the holding power of screws so that they may pull out prior to fracture healing (see Fig. 4.23); (b) comminution so severe that anatomical reduction may be impossible; (c) avascular necrosis of the humeral head; (d) dif- ficult techniques and imperfect implants. We are still grappling with the biological problems, but the types of implants available are steadily improving.

4.2 Classification

Any classification is useful only if it aids the surgeon Fig. 4.3. Blood supply to the humeral head. The main blood in the management of a given injury. The proposed supply to the humeral head is from the anterior humeral cir- classification (Table 4.1), adapted from the previous cumfl ex artery from which arises the arcuate artery entering reports of Codman and Neer, should, if followed, lead the head from the small metaphyseal area on the inferior aspect of the head the surgeon to logical management based on the nat- ural history of the various fracture types. The two major considerations in this classification are, first, the anatomical features of the fracture, i.e., whether the fracture is through the anatomical neck separat- ing the head fragment (intracapsular) or through the surgical neck (extracapsular), and second, whether

Table 4.1. Classification of fracture types

ab 1. Stable 2. Unstable A. Minimally displaced Fig. 4.4a,b. Stable and unstable fractures of the proximal B. Displaced humerus. a Typical impacted stable fracture in which the 1. Two-part shaft and head move as one unit. b An unstable fracture of (a) Lesser tuberosity the proximal humerus, characterized by movement between (b) Greater tuberosity the shaft and head fragments (c) Surgical neck (d) Anatomical neck 2. Three-part – Surgical neck (a) Plus lesser tuberosity will have a very different outcome than will a fracture (b) Plus greater tuberosity with the same number of segments but with inher- 3. Four-part – Anatomical neck ent instability. Stability must be assessed by a careful Plus tuberosities clinical as well as a complete radiological investiga- 4. Fracture-dislocation (a) Two-part – with greater tuberosity tion. (b) Three-part I. Anterior, with greater tuberosity II. Posterior, with lesser tuberosity 4.1.6 (c) Four-part Surgical Difficulties I. Anterior II. Posterior 3. Articular If surgery is the answer for some of the unstable (a) Head impaction – (Hill-Sachs) fracture types identified as having a poor outcome if (b) Articular fractures treated by nonoperative means, why has it not been 1. Humeral head split universally adopted? The answer is obvious; surgery 2. Glenoid rim is not without its own set of problems, such as: (a)

4.2 Classification

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the fracture is stable, i.e., the head and shaft are 4.3.1 impacted and move together, or unstable. Stable Fractures The value of this particular classification and indeed all classifications have been questioned As in other areas of the body, stability must here be (Siebenrock and Gerber 1993; Burstein 1993; Sidor et considered a relative and not an absolute concept. al. 1993; Tamai et al. 2002; Brorson et al. 2003.). A stable fracture is one that cannot be displaced by In these studies, the rate of interobserver error was physiological forces. A rigidly impacted fracture of found to be unacceptably high, thereby invalidating the proximal humerus caused by compressive forces the classification, sparking an angry response from fulfills these criteria, no matter how many fragments many observers. may be present. Soft tissue hinges are most likely to Do the studies mean that these concepts in the be intact, so that avascular necrosis is improbable. classification are invalid? This depends on one’s view Impaction of the cancellous bone allows early pain- of classifications and their use in clinical medicine. free motion and rapid union, both contributing to I believe that for decision-making in individual a good functional result. The natural history of the cases, the classification should serve only as a guide stable fracture is usually favorable; therefore surgery, to treatment. The surgeon must consider not only except in the most unusual circumstances, is meddle- fracture factors, which may vary for each individual some and dangerous. (Court-Brown et al. 2002) case, but also patient factors, both of which comprise Exceptions to this rule are stable fractures with the “personality” of the fracture. The present classifi- unacceptable displacement, for example, an impacted cations can serve as a guide but cannot be used as a stable fracture with excessive angulation in a young “cookbook.” patient. Unacceptable displacement cannot be defined For clinical trials and studies, the classification is by a number, but can be ascertained only after a care- also used to compare cases from different centers. ful assessment of all the factors making up the per- For this purpose, high inter-observer error is dis- sonality of the injury. turbing; nevertheless, we must continually strive to understand existing classifications and change them when underrated. Also important, as pointed out by 4.3.2 Brorson et al. (2003), formal training in learning the Unstable Fractures details of the classification markedly improved the inter-observer interpretation. The state of the soft tissue envelope will determine the degree of instability present. A grossly unstable fracture will allow the fragments to move indepen- dently of each other, as noted in the clinical and 4.3 radiographic assessment. Instability of the major Natural History and Surgical Indications fragments may result in pain, as well as in delayed union, both contributing to prolonged immobiliza- A careful study of the natural history of each of the tion and a less than perfect result. fracture types in the proposed classification will Displaced fractures of the articular fragment greatly aid the surgeon in his final decision-making through the anatomical neck often result in avascu- process. Delayed union or nonunion and avascular lar necrosis. Thus, the natural history of the unstable necrosis are the major complications affecting proxi- proximal injury is markedly different from that of the mal humeral fractures. By indicating those fractures stable injury and requires a different approach. which are likely to end in a poor result with closed methods, we hope the surgeon will, by deduction, come to open treatment as the preferred alternative. 4.3.2.1 In general, those fractures where open reduction Minimal Displacement must be considered as a treatment option because of a poor prognosis with nonoperative care are marked A minimally displaced fracture usually implies a less in red in Table 4.2. violent force and the presence of some soft tissue hinges. Neer (1970) arbitrarily chose less than 1 cm of displacement as indicating some attached soft tissue. This must, of course, be confirmed by clinical exami- nation, often with image intensification. If soft tissue

4.2 Classification

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Table 4.2. Fractures of the proximal humerus. Classification and treatment guidelines. Fractures in the red boxes should be considered for open reductions and internal fixation

2 Part

3 Part

4 Part

ant

Fracture dislocation

post

articular impaction

4.3 Natural History and Surgical Indications

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hinges have been retained, the ultimate prognosis is the acromion, acting as a block to abduction. To cor- good, no matter how many fragments are present. rect both the mechanical block and the loss of rotator Vascularity of the head fragment is usually assumed, cuff function, surgery is mandatory. We regard the and surgery is virtually never indicated for this type displaced retracted greater tuberosity fracture as an of injury (Fig. 4.5). absolute indication for surgery. Greater tuberosity fractures occur more com- monly in association with anterior dislocation of the 4.3.2.2 shoulder, and, as will be described in the section on Major Displacement fracture-dislocation, they rarely require open reduc- tion in that particular situation (Fig. 4.6b). The fractures with major displacement will be con- sidered according to the anatomical structures and Surgical Neck Fractures. Impacted fractures through the number of segments involved. the surgical neck are common and usually minimally displaced, thus requiring only closed treatment. However, shearing forces may cause displacement Two-Part and instability. The large proximal fragment usually has sufficient soft tissue attachment to ensure the Displaced fractures may occur through any of the viability of the humeral head. Associated undisplaced four segments previously described. The outcome of fractures into the tuberosities are common, but they a single fracture through these segments will vary do not alter the natural history because the soft tis- considerably, depending upon the retained soft tissue sues are retained. Avascular necrosis is rare, unless envelope. the blood supply is destroyed by injudicious surgery; however, union may be delayed because of the gross Lesser Tuberosity. Pure avulsions of the lesser tuber- instability of the main fragments. osity are rare and are of little clinical significance. These grossly unstable fractures usually occur However, an isolated lesser tuberosity fracture should in young patients with strong cancellous bone and always alert the surgeon to the possibility of a pos- are usually caused by high-energy shearing forces. terior dislocation of the shoulder, with which it is Severe pain and delayed union will require prolonged frequently associated. Unless associated with some immobilization, which may lead to permanent stiff- other major displaced fragment, closed treatment ness despite lengthy rehabilitation. Open reduction only is indicated. and stable internal fixation, using standard tech- niques, will immobilize the fracture sufficiently to Greater Tuberosity. A displaced isolated avulsion reduce pain, ensure rapid healing, and allow early fracture of the greater tuberosity is indicative of a loss motion with improved results. We regard this frac- of function of the rotator cuff (Fig. 4.6a). In the two- ture as a relative indication for surgery, especially in part pattern, the bony fragment may retract under young patients with good bone (Fig. 4.7).

a b Fig. 4.5a,b. Unstable, mini- mally displaced three-part fracture of the proximal right humerus in a 67-year-old woman (a). Treatment con- sisted of a sling and a swathe for 3 weeks, until the pain sub- sided, and then a program of physiotherapy. At 8 weeks (b), the fracture had healed in a good position. Note the slight inferior subluxation, which is almost inevitable in these indi- viduals. When rehabilitation is complete, the inferior sublux- ation usually reduces sponta- neously

4.3 Natural History and Surgical Indications

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Fig. 4.6a,b. Fracture of the greater tuberos- ity. a An avulsion-type fracture of the greater tuberosity. This is a true avulsion of the rota- tor cuff, in which the bone lodges under the acromion and acts as a mechanical block. Surgery is mandatory. b Fracture of the greater tuberosity has occurred at the time of anterior dislocation of the humeral head. In this situation, the tuberosity is in its cor- rect position and does not retract. Therefore, reduction of the dislocation usually leads to an anatomical reduction of the tuberosity to the shaft, and surgery is rarely necessary a b

a b

c d

Fig. 4.7a–d. Unstable three-part fracture through the proximal humerus. a Anteroposterior and b lateral radiographs showing an unstable oblique fracture in the upper humerus with an exten- sion through the greater tuber- osity. This fracture occurred when a 33-year-old woman was thrown from a horse and struck a tree. The fracture was grossly unstable on clinical examination, and, in consultation with the patient, treatment consisted of open reduction and internal fi x- ation using a dynamic compres- sion (DC) plate with a lag screw across the fracture through the plate (c, arrow; d). Excellent sta- bility was obtained. The patient regained full shoulder motion within 10 days of injury

4.3 Natural History and Surgical Indications

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Anatomical Neck. Two-part fractures involving the tuberosity or both. Since the proximal fragment is anatomical neck are rare. Since the head segment large, some soft tissue envelope is usually retained. is covered by articular cartilage, displaced fractures Avulsion of either tuberosity diminishes the blood through the anatomical neck are associated with a supply to the humeral head, but avascular necrosis is high incidence of avascular necrosis (see Fig. 4.2a). uncommon, although it occurs with greater incidence Because of the instability of the bone fragments, non- than in the two-part surgical neck fracture. union may also occur. In the two-part anatomical Of much greater clinical significance is the rota- neck fracture with displacement, surgery should be tory deformity of the proximal fragment caused by performed if closed manipulation fails to restore the the avulsion of the tuberosities. If the lesser tuberosity local anatomy. In such cases, care should be taken to containing the subscapularis is avulsed, the proximal preserve any remaining soft tissue attachments. If fragment is externally rotated by the remaining rota- compression of the cancellous fracture is achieved by tor cuff, the supraspinatus, infraspinatus, and teres surgery, rapid healing of the cancellous fracture will minor (Fig. 4.8). If the greater tuberosity is avulsed, ensue, but avascular necrosis will not be prevented. the proximal fragment is internally rotated by the Some patients may manage reasonably well with an unopposed pull of the subscapularis (Fig. 4.9a). In avascular head if the fracture has healed and the head both instances, the unstable shafts may be driven into revascularizes in time to prevent collapse. the mass of deltoid muscle and may be anterior to the proximal fragment. Poor bone contact will lead to Three-Part delayed union or nonunion in most cases. The presence of a round proximal fragment with The three-part fracture consists of a large displaced the appearance of a full moon on the anteroposte- proximal fragment through the surgical neck, associ- rior radiograph should alert the astute surgeon to ated with an avulsion of either the lesser or greater this injury (Fig. 4.9b). Open reduction and internal

Fig. 4.8. Three-part fracture of the proximal humerus in which the lesser tuberosity is avulsed, allowing the proximal fragment to externally rotate. The radiological appearance of the head is that of a full moon on the anteroposterior view

a b

Fig. 4.9. a Three-part fracture of the proximal humerus with avulsion of the greater tuberosity. In this particular case, the remaining attachment of the subscapularis through the lesser tuberosity internally rotates the proximal fragment 90°, again appearing radiographically as a full moon on the anteropos- terior view. This is clearly seen in b

4.3 Natural History and Surgical Indications

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fixation should always be performed if delayed union destroy any remaining blood supply (Fig. 4.11). The and nonunion are to be prevented. avulsed abductor mechanism, often in one large frag- ment consisting of the greater and lesser tuberosities with the intervening long head of biceps tendon, may Four-Part be replaced without disturbing the impacted head. If the impacted fragment causes a block to motion The four-segment fracture is the most difficult to during examination of the patient under anesthesia, treat and is associated with the poorest results. Added then careful open reduction of the fracture is indi- to the problems of the three-part fracture, namely cated. The technique must be atraumatic, so that any delayed union or nonunion, is avascular necrosis of remaining blood supply to the humeral head is not the humeral head. The pathognomonic feature is the compromised (Figs. 4.12, 4.13) (Jakob et al. 1991). small, crescentic, proximal articular fragment sev- ered from the anatomical neck of the humerus. This Unstable Type. This fracture is usually caused by a fragment may be devoid of all soft tissue, making high-energy shearing force, tearing the soft tissue avascular necrosis a certainty, irrespective of treat- envelope, thereby commonly leaving the humeral ment. Occasionally, some capsular attachments may head avascular. remain; therefore, the presence of a small head frag- If the head fragment is free, it must be reduced to a ment does not necessarily doom the head to avas- satisfactory position by either closed or open means, cularity. as will be described. A completely free head may have There are two types of four-part fracture patterns, to be discarded during surgery and replaced with a each differing markedly in treatment and outcome. prosthesis; however, in young patients, every effort In the first type, the small crescentic head fragment should be made to retain the head fragment. is impacted and stable, whereas in the other, the head is unstable and not impacted. (Fig. 4.10a, b). Fracture-Dislocation Impacted Stable Type. This fracture pattern is caused by a fall on the outstretched arm in the abducted Fracture-dislocations may be considered an exten- position. In this mechanism, the head is driven into sion of the two-, three-, and four-segment classifi- the porotic neck, splitting the tuberosities. The soft cations. As in our previous discussion, the ultimate tissue remains intact, usually maintaining the blood prognosis will depend upon the probability of non- supply to the head, unless it is destroyed by injudi- union or avascular necrosis of the fracture. Add to cious surgery. this the problems associated with the dislocation, If the small head fragment is impacted and not such as irreducibility of the humeral head or impac- acting as a mechanical block to movement, surgery tion of its articular surface, and one can see why should be avoided, as attempts at open reduction may this injury has the worst prognosis of any in this region. In the two- and three-part fracture-disloca- tions, the proximal fragment is usually of sufficient size to retain capsular attachments, making avascular necrosis uncommon. The retention of at least one tuberosity almost always ensures viability of the humeral head. In the four-part fracture-dislocation, however, the head fragment is usually completely detached and avascular.

Two-Part. The two-part anterior fracture-disloca- tion is associated with an avulsed greater tuber- osity (Fig. 4.14a). In older patients with anterior a b humeral head dislocations, massive tears through the rotator cuff are more common than avulsions Fig. 4.10a,b. Four-part fracture patterns. There are two types of the greater tuberosity and are often overlooked of four-part fracture patterns, each differing markedly in (Fig. 4.14b). Satisfactory reduction is usually treatment and outcome. In the fi rst type, the crescentic head fragment is impacted and stable (a), whereas in the other the achieved by closed means with or without a gen- head is unstable (b) eral anesthetic. In almost all cases, closed reduc-

4.3 Natural History and Surgical Indications

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aa

b c

d e

f g

Fig. 4.11a–g. Impacted four-part fracture of the proximal humerus with valgus position of head. a Extreme valgus position of the head driven into the soft cancellous bone by the abducted shoulder. Note the avulsion of both the greater and lesser tuber- osities, which remain in their normal position. This is clearly seen on the anteroposterior and lateral radiographs (b,c) and is emphasized in d. The impacted valgus position of the head is clearly seen, as are the greater and lesser tuberosity avulsions, marked by the two arrows. This 49-year-old woman was taken to the operating room and the shoulder was manipulated under general anesthesia. Since there was no block to motion and the head and shaft fragments moved together, her injury was treated nonoperatively. At 1 year (e) the fracture has united with no evidence of avascular necrosis. The patient’s range of motion is almost full (f,g) and she functions normally

4.3 Natural History and Surgical Indications

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ab c

de f

Fig. 4.12a–f. Atraumatic dissection. a Three-part fracture of the proximal humerus. b Head fragment being reduced into its normal position with a periosteal elevator. The surgeon’s fi nger is also an excellent reduction tool and may be less traumatic. c Reduction is complete. Note that the capsular attachment to the proximal fragment has not been interfered with, thereby not interfering with the blood supply to the humeral head. d Anteroposterior and e lateral x-ray of three-part fracture treated by this atraumatic method with an excellent result (f)

a

Fig. 4.13. a This 59-year-old woman sustained an impacted four-part type fracture of the proximal humerus. b Operative intervention and fi xation resulted in an avascular necrosis of the humeral head. If this fracture is to be operated on, it must be done through atraumatic techniques that do not interfere with the blood supply (see Fig. 4.12) b

4.3 Natural History and Surgical Indications

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Fig. 4.14a–c. Two-part fracture-dislocations. a Two-part anterior fracture-dislocation associated with an avulsed greater tuberosity. b Anterior dislocation of the shoulder asso- ciated with an avulsion of the rotator cuff. c Anterior dislocation of the shoulder with an interposed long head of biceps tendon pre- a b c venting reduction of the dislocation

tion with no surgical intervention is indicated. In small head fragment has no attached soft tissue rare instances, the long head of biceps tendon may and will be avascular; therefore, the prognosis act as a block to reduction, causing either irreduc- must be guarded. Closed manipulation under gen- ibility of the dislocation or persistent displacement eral anesthesia may restore the head fragment to of the fracture (Fig. 4.14c). In this situation, open its normal position. However, in our experience, reduction is indicated. this is extremely difficult, and anatomical reduc- A two-part posterior fracture-dislocation is asso- tion is rarely achieved. Open reduction is usually ciated with an avulsed lesser tuberosity. Closed treat- indicated, but the patient must be informed that ment is usually sufficient for this injury. avascular necrosis of the humeral head is likely. In young patients, every effort should be made to Three-Part. The major feature of the three-part retain the head fragment; in older patients it should dislocation is the large proximal fragment created be discarded in favor of a prosthesis (Hawkins and by the fracture of the surgical neck of the humerus Switlyk 1993). (Fig. 4.15a). Some capsular tissue is almost always retained on the large head fragment, ensuring its via- bility. If the head fragment is displaced anteriorly, the 4.3.3 greater tuberosity is usually fractured, whereas the Articular Fractures lesser tuberosity is retained. In the posterior fracture- dislocation, the greater tuberosity is usually retained, whereas the lesser is avulsed. 4.3.3.1 In the three-part fracture-dislocation, closed Impacted (Hill-Sachs) manipulation with general anesthesia may restore the proximal fragment to an anatomical position. Impaction of the articular surface, the so-called Hill- (Fig. 4.15b–e) If the proximal fragment cannot be Sachs lesion, may occur with any type of fracture-dis- reduced because of soft tissue interposition, then location. In anterior dislocations the impaction of the open reduction is mandatory. If gross instability of articular surface occurs posteriorly, the reverse being the fracture remains after closed reduction of the dis- true for the posterior dislocation (Fig. 4.17). Very location, then open reduction and internal fixation little can be done surgically to restore the normal are desirable. The surgeon must respect the soft tissue anatomy, and recurrent dislocation may ensue, to be attached to the head fragment envelope in order not dealt with secondarily by standard means. In late, to destroy the attached soft tissue. unreduced fracture-dislocation the defect may be so large that specialized techniques such as insertion Four-Part. Fracture-dislocations involving the of the subscapularis tendon into the anterior defect anatomical neck of the humerus propel the small (McLaughlin 1960) or osteotomy of the humerus crescentic head fragment inferiorly, anteriorly or scapular neck for the posterior defect (Müller et (Fig. 4.16a–e), posteriorly, or occasionally intra- al. 1979) may be required to restore stability to the thoracically (Fig. 4.16f,g). In almost all cases, this shoulder (Fig. 4.18).

4.3 Natural History and Surgical Indications

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b c

a

Fig. 4.15a–g. Three-part fracture- dislocation. a In this anterior dislo- cation, the fractured humeral head is seen lying anterior to the glenoid labrum with an associated greater tuberosity. b Anteroposterior and c transcapsular lateral radiographs of d e a 34 year old male in a motor vehicle accident. The head was clearly dis- located, but because of this patient’s large size, details were diffi cult to determine. d,e The patient was given a general anesthetic, and using closed manipulation under image intensifi - cation the humeral head was reduced. f Note on the radiograph image in the operating room the excellent reduc- tion obtained by closed manipula- tion. g The patient was treated with an abduction splint until the fracture healed, with an excellent end result and no avascular necrosis f g

4.3.3.2 Humeral Head ment problems and require careful analysis before a definitive decision is made.

As in any other joint, major shearing forces applied to the joint surface may shatter the articular cartilage. 4.3.3.3 The degree of articular damage may vary from small Glenoid Labrum osteochondral fractures to major splits in the humeral head. In this situation, we must revert to basic princi- The usual pathological lesion associated with an ples in the management of any joint fracture, i.e., open anterior dislocation of the shoulder is an avulsion of anatomical reduction and stable fixation, followed by the glenoid labrum (Bankart lesion) and a posterior early motion if technically possible (Fig. 4.19). The impaction fracture of the humeral head (Hill-Sachs upper extremity, however, is much more forgiving lesion). On occasion, the glenoid labrum is avulsed than the lower extremity; hence, closed methods may with a small segment of bone that, upon reduction, be more prudent than open methods, which could does not affect the acute stability of the shoulder, but jeopardize the blood supply to the small fragments. may be associated with recurrent dislocation. Rarely, These fractures present extremely difficult manage- with anterior dislocation, a large anterior segment of

4.3 Natural History and Surgical Indications

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ab

c

d e ୴୴

4.3 Natural History and Surgical Indications

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f g

Fig. 4.16a–g. Four-part fracture-dislocations. a The head is anteriorly dislocated. Both the lesser and greater tuber- osities are avulsed. The humeral head may be attached by a small amount of capsule inferiorly or may be completely devoid of soft tissue attachment. The presence of the inferior triangle of bone is a good prognostic sign and may indicate that the blood supply is intact. b Anteroposterior and lateral radiographs of a four-part anterior fracture- dislocation. The lower arrow points to an avulsion from the glenoid labrum, the upper arrow to that portion of the glenoid from which the bone was avulsed. Open reduction and internal fi xation were performed through an anterior deltopectoral approach. c The greater tuberosity was replaced with a lag screw, the major fracture with a lag screw plus T plate, and the glenoid fracture with a screw and staple. d,e The result at 18 months, with full movement and no avascular necrosis. f,g Intrathoracic fracture-dislocation of the humeral head. f Humeral head in the left pleural cavity outlined by the arrows; chest drain in place. g Appearance after removal of the humeral head, 12 months after trauma

Fig. 4.17a,b. Impacted articular frac- tures. Impaction of the articular surface may occur with any type of fracture-dis- location. a In anterior dislocations, the impaction of the articular surface occurs posteriorly. b In posterior dislocations, the impaction occurs anteriorly ab

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a b c

d e f

gh

Fig. 4.18a–h. Late posterior dislocation of the shoulder. a,b Anteroposterior and lateral radiographs of a 48-year-old epileptic who had sustained a posterior dislocation of the left shoulder 4 months previously. c Tomogram showing large anterior humeral head defect. d Surgery through an anterior approach reduced the head; it was maintained with Kirschner wires and the sub- scapularis tendon was inserted into the defect. e The Kirschner wires were removed with stability maintained. f Intraoperative photograph showing the massive defect. g,h The fi nal result: joint narrowing is apparent but function is satisfactory

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a b c d

e

Fig. 4.19a–e. Articular fractures of the humeral head. a Impaction of the articu- lar cartilage. b Anteroposterior radiograph of a 19-year-old motorcyclist with an injury to the proximal humerus. Note the articular impaction, the marked commi- nution, and the fracture of the proximal shaft. c Open reduction and internal fi xa- tion included elevation of the articular surface and bone grafting, as well as stable internal fi xation using interfragmental screws and T plates. d After removal of the fi xation 3 years after injury, the anteroposterior radiograph shows no evidence of avascular necrosis, and a good cartilage space. e Function at that time was satisfac- tory, although defi nite restriction of external rotation was noted

the glenoid is fractured and displaced, rendering the a major portion of the articular surface of the joint, shoulder unstable (Fig. 4.20). This fracture may occur it requires anatomical reduction for optimal results. with simple dislocations or with the more complex Closed treatment cannot accomplish this; therefore, fracture-dislocations. operative fixation is mandatory when the fragment If displaced, open reduction and internal fixation is large enough to affect the stability of the joint. The are desirable for the following reasons: (a) redisplace- opposite lesion may occur with a posterior disloca- ment of the shoulder will readily occur with external tion, i.e., a large posterior fragment of the glenoid rotation because of the loss of the anterior portion of labrum may be fractured and will require operative the glenoid labrum; (b) since the fragment contains reduction.

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a

b c d e

Fig. 4.20a–e. Fractures of the glenoid labrum. a A fracture of the glenoid labrum causing anterior instability of the shoulder. b Antero- posterior radiograph shows avulsion of the inferior half of the anterior glenoid labrum. c This is more clearly seen on the axillary view. d The fragment was fi xed by open reduction and internal fi xation using a Kirschner wire and a lag screw. e Stability was restored to the shoulder and function was good

4.4 patient, his or her expectations, and the degree of vio- Management lence involved in the injury. For example, a markedly displaced fracture-dislocation through the proximal 4.4.1 humerus of a young patient with normal cancellous Assessment bone has a vastly different outlook from that of a fracture-dislocation of similar appearance caused by 4.4.1.1 a simple fall in an elderly individual. Physical examina- Clinical tion will determine both the general state of the patient and the local condition of the limb. Complicating fac- The first step in logical decision making is a care- tors such as severe soft tissue injury, whether open or ful clinical and radiological assessment. A painstak- closed, and the presence of neurovascular injury will ing history may indicate the physiological state of the affect the decision to operate and its timing.

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Careful manipulation of the limb will often reveal damage. Surgery is indicated where the probability of more information about the stability of the fracture such complications with closed treatment is high, as than the radiograph. In grossly unstable fractures, the previously discussed. The surgeon should assess the humeral shaft may be easily palpated in the deltoid personality of the injury: this includes the fracture pat- muscle mass, moving independently of the proximal tern, the condition of the limb, and the patient, as well fragment. as the surgeon’s own expertise. [The term “personality of the fracture” was first coined by Nicoll (1964) in 4.4.1.2 connection with fractures of the tibia; see Sect. 17.2]. Radiological These factors are considered in the decision-making algorithm (Fig. 4.21). Careful radiological assessment is required prior to choosing a definitive treatment method. Standard 4.4.2.1 roentgenograms of this area are often confusing and Stable Fractures may be supplemented with tomograms or computed tomography (CT) scans. Tomographic investigation, If the clinical and radiological assessment indicates a especially 3-D reconstruction, will reveal the position stable fracture, i.e., the patient can actively move the and size of the humeral head fragment, the number extremity without pain, and the limb can be moved of segments, and the degree of instability. passively with little pain and no abnormal motion Through a careful combination of the clinical between the shaft and head fragments, the patient and radiological assessments, a proper management should be treated nonoperatively. The blood supply to scheme for the individual patient will evolve. a fractured proximal fragment is often so fragile that ill-advised open reduction will threaten the viabil- 4.4.1.3 ity of the humeral head and must be avoided at all Examination Under Anesthesia costs in stable situations (see Figs. 4.10 and 4.13). The arm may be immobilized in a sling and early motion In most patients, a careful clinical assessment will started immediately. An excellent functional result indicate the degree of instability without the need for may be expected in this situation (Rasmussen et al. a general anesthetic. These individuals may be exam- 1992; Koval et al. 1997; Court-Brown et al. 2002). The ined with adequate sedation, their fracture viewed only exception to this rule would be a stable fracture on the image intensifier, and the degree of instability with such gross displacement that the function of the ascertained. With those patients in whom stability extremity would be adversely affected. We agree with cannot be assessed because of severe pain, examina- Neer that an impacted humeral neck with an adduc- tion under anesthesia with image intensification will tion deformity of more than 50° would certainly be helpful. Also, in some fracture-dislocations, the affect the end result, and in rare circumstances this radiographs may be confusing; therefore, examina- would constitute an indication for open reduction. tion under anesthesia may serve two purposes: first, giving more information about the injury and second, 4.4.2.2 affording the surgeon the possibility of treatment by Unstable Fractures closed reduction (see Fig. 4.15). The surgeon should be prepared to proceed with immediate definitive If the clinical and radiological assessment indicates surgical management if indicated. an unstable fracture, i.e., independent motion is pres- ent between the shaft and head fragments, further decision-making will depend upon the degree of dis- 4.4.2 placement and instability present. Decision-Making Minimally Displaced The natural outcome of most stable and minimally dis- placed unstable proximal humeral fractures is a healed If the fracture is minimally displaced (Fig. 4.5a,b), no fracture and a satisfactorily functioning extremity matter how many segments are involved, one might (Court-Brown et al. 2002). However, unstable frac- reasonably expect the presence of an intact soft tissue tures or fracture-dislocations have a high probabil- envelope in some portion of the fracture. Examina- ity of delayed union or nonunion, avascular necrosis, tion under image intensification may indicate lack irreducibility of the dislocation, and articular cartilage of independent motion between the shaft and the

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Proxial Humeral Fractures

Stable Unstable

Minimal Significant displacement displacement

Early Immobilize If patient motion infirm, If normal senile, has expectations low expectations

Motion Symptomatic care when pain-free and healing Pseudarthrosis Good bone Poor bone initiated may result (osteoporosis)

Open reduction and Viable head Nonviable head internal fixation using methods of (a) Cement augmentation stable fixation (b) Open reduction and stabilization with Kirschner wire and tension band fixation Prosthesis

Fig. 4.21. Decision-making algorithm for proximal humeral fracture (c) Fractures interne

proximal fragment at various degrees of rotation and edly. In Sect. 4.3 we discussed in some detail those abduction, confirming the presence of an intact soft injuries requiring open reduction. Having deter- tissue envelope. Patients with these fractures have mined that the fracture at hand would best be treated more pain than do patients with a firmly impacted by open reduction and stable internal fixation, other stable fracture; therefore, immobilization is required factors must now be considered. until sufficient fracture healing has taken place to Even in the best of circumstances surgery may be render the patient pain-free. This is followed by a difficult; therefore, the stated goal of open reduction period of active rehabilitation of the injured limb; – stable fixation allowing early motion – may not this period may vary from 2 to 6 weeks, depending be realized because of the many technical problems upon the specific fracture. Since most fractures of inherent in this area. Therefore, surgery should only the proximal humerus fall into the above two types, be performed in cases where the surgeon is confident either the stable or the minimally displaced unstable of overcoming these difficulties and experienced fracture, it follows that most fractures of the proximal enough to achieve the stated goal. Of prime impor- humerus may be managed by closed means. tance is the general state of the patient.

Displaced Poor Patient Expectations. If the patient is infirm, senile, and with low functional expectations, the If a careful assessment indicates an unstable fracture surgeon should consider nonoperative symptom- or fracture-dislocation, the situation changes mark- atic treatment, i.e., judicious neglect. Such patients

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are immobilized in any type of binder or sling for ent, but also the physiological state of the bone. It is comfort. Between the fourth and sixth week their obvious that this state is not an absolute, i.e., either pain usually subsides. Delayed union and eventually good or bad, but a spectrum. Assessment of the bone nonunion become apparent in many cases of three- may be difficult; nevertheless, it is extremely impor- and four-part fractures. With persistence of this non- tant if major errors in technique are to be avoided. treatment, the surgeon may be pleasantly surprised Many of these fractures occur in elderly individu- at the degree of shoulder function regained by these als with osteoporotic bone. Standard AO/ASIF tech- patients. By 6 months, many patients have little pain niques will fail because of the poor holding power of and a surprisingly good range of motion (Fig. 4.22). the screws in such bone. Therefore, the surgeon might They complain of weakness in their extremity and achieve an excellent-looking postoperative radio- inability to lift heavy objects, but usually carry out graph, but will find that with early motion the screws their normal daily routine without difficulty. We will often pull out, with disastrous results (Fig. 4.23). recommend this pseudoarthrosis treatment only in Other techniques to be described are preferable in exceptional circumstances, such as for patients with that situation (Figs. 4.24, 4.25). Also, newer implants severe physical or mental disease. are now available, which may be used in select cases where poor bone is present. Normal Expectations. If our assessment reveals that If the bone is normal, i.e., if the state of the skeleton the patient has expectations for a normally function- is good enough to ensure the holding power of the ing upper extremity, it then becomes necessary to screws, anatomical open reduction followed by stable carefully appraise not only the type of fracture pres- internal fixation is indicated. This may be readily

a b

c d

Fig. 4.22a–d. An 82-year-old woman fell and sustained a three-part fracture of the right proximal humerus, seen on the antero- posterior and lateral radiographs (a). The patient was treated with a short period of immobilization followed by rehabilitation. b At 2 years, a clear pseudoarthrosis is seen on the anteroposterior radiograph. c,d The patient’s function, however, was excellent, with a full range of motion and minimal discomfort. Her major disability was weakness in the right arm

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Fig. 4.23. Anteroposterior radiograph taken 4 days following an excellent internal fi xation of a four-part proximal humerus fracture in a 79-year-old woman, show- ing failure of the fi xation because of osteoporotic bone, so common in proximal humeral fractures in the elderly

a b c d

Fig. 4.24a–d. Impaction tension band technique of internal fi xation. If open reduction is indicated in elderly patients with osteoporosis, the technique will afford good stability. a After exposing the fracture, a small portion of soft osteoporotic bone should be curetted from the femoral head and neck. b This will allow impaction of the shaft into the defect so created. This impaction will restore some stability to the unstable fracture, and the head and shaft can move as a unit. c Fixation is achieved with multiple Kirschner wires into the head and shaft, crossing the tuberosities as necessary. d A tension band wire is then inserted around the Kirschner wires over the inferior portion of the rotator cuff

achieved in the two- and three-part configurations, becomes a major symptomatic problem, secondary unless comminution or destruction of the articular prosthetic replacement or shoulder arthrodesis may cartilage is great. Early motion may be instituted be performed if necessary. and a good result can be expected (see Fig. 4.16a–e) If the pre- or intraoperative assessment indicates (Esser 1994). the presence of bone so poor that the holding power In the four-part fracture, the result is more depen- of screws would be negligible, other measures must dent on the state of vascularity of the head fragment, be taken to achieve stability. The surgeon must first which may compromise the end result. In the young determine whether the proximal fragment is viable individual, however, we feel that every effort should or not viable. In two- and three-part fractures the be made to retain the crescentic head and to institute head is usually viable, unless the soft tissue is indis- early rehabilitation. If the ensuing avascular necrosis criminately removed by the surgeon. A small crescen-

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a bc

de f

g h

Fig. 4.25a–h. Clinical application of impaction tension band technique. a,b The anteroposterior and lateral radiographs of this 73-year-old man show the typical moon-shaped head of a three-part unstable fracture of the right proximal humerus. The arrow points to the anterior location of the shaft with no contact to the humeral head. The fracture was exposed through a deltopectoral approach. c,d A small amount of bone was curetted and the shaft was impacted and fi xed with multiple Kirschner wires and a tension band wire, as seen on the postoperative radiographs. e,f At 8 months the radiographs show sound union. g, h The clinical photographs show excellent function

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tic head segment in the four-part fracture is almost for which this technique is obviously unsuitable. The always avascular. above two alternatives are more suitable for that par- If the head fragment is viable, i.e., if the proximal ticular problem. segment is vascular as in the two- and three-part 3. Newer implants such as the locking plate (inter- fractures, but the bone is so poor that it is unlikely nal fixator) (see Fig. 4.34), the blade plate, and on that a screw will hold, other options are available. occasion, the locked intramedullary (IM) nail. Because the viability of the proximal fragment is not in question, it should always be retained and the use If the head is nonviable – as in a four-part fracture of a prosthesis should not be considered. The other – i.e., if the crescentic fragment is totally avascular options are: and the bone is poor, a unipolar prosthetic replace- ment should be inserted primarily, great care being 1. Impaction tension band technique. By curettage taken to restore the function of the rotator cuff by of some cancellous bone from the proximal frag- carefully reattaching the rotator cuff or the avulsed ment and impaction of the shaft into that area, sta- tuberosities (Fig. 4.26; Hawkins and Switlyk 1993; bility may be restored to the fracture (Fig. 4.25a, Moeckel et al.1992, Goldman et al 1995; Bosch et al. b). Multiple Kirschner wires through the fracture 1998; Demirhan et al. 2003). fragments surrounded by a tension band wire will maintain this stable situation (Fig. 4.24c,d). Screws are not used; fixation is dependent upon the mul- tiple Kirschner and tension band wires (Fig. 4.25; 4.4.3 Kocialkowski and Wallace 1990; Flatow et al. 1991; Surgical Technique Jaberg and et al. 1992; Cornell et al. 1994). 2. Cement composite fixation. A second alternative is to use cement in the intramedullary portion of the 4.4.3.1 fracture to improve its stability or in the predrilled Timing screw holes to improve the holding power of the screws. Since fractures of the proximal humerus are articular or periarticular injuries, we prefer to operate as soon If the surgeon has begun a traditional type of open as possible, once the decision has been made that sur- reduction and finds that the screws are not holding gery is necessary. This will, of course, depend upon in the metaphysis, nuts may be affixed to the corti- the state of the soft tissues and the precise time that cal screws to increase their holding power. However, the patient is seen following the accident. Surgery in the upper humerus, the major problem is usually should never be performed through compromised poor fixation of the screws in the proximal fragment, soft tissues.

a b

Fig. 4.26a,b. Four-part fracture; treatment by unipolar prosthesis. a Anteroposterior radiograph indicating an unstable four- part proximal humerus fracture. A small crescentic head is nonviable. b It was replaced with a unipolar Neer-type prosthesis. Note the rotator cuff reposition with a wire suture

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4.4.3.2 Approaches

Where an extensile approach is indicated, the stan- dard anterior deltopectoral approach will suffice (Henry 1927). Since it is extensile, the incision may be continued distally to expose the entire humeral shaft on its anterolateral surface. The posterior approach may be used for irreducible posterior fracture-dislocations, but is not indicated for other reconstructive procedures in the area of the shoul- a der. However, the trend at this time is for more limited approaches for fracture care, in order to preserve the blood supply to the bony fragments (biological inter- b nal fixation). In the shoulder, a limited approach to fixation by tension band techniques and intramedul- lary devices is the deltoid split with or without acro- mion osteotomy.

Anterior Deltopectoral Approach

The anterior incision should be made along the medial border of the deltoid muscle extending lat- erally to the humeral shaft (Fig. 4.27a). The delto- c pectoral triangle is identified and the cephalic vein protected. Proximal exposure will depend upon d the fracture configuration. If the surgical neck is fractured without extension into the tuberosities, Fig. 4.27a–d. Anterior approach to the proximal humerus. a Anterior incision. b Deep dissection in the deltopectoral trian- very little deltoid reflection is necessary (Fig. 4.27b), gle. Note position of the long head of the biceps muscle. c Line whereas if greater access to the proximal humerus of resection of deltoid from clavicle (heavy dotted line) and is required, a more radical removal of the deltoid level of acromion osteotomy (small dotted line). d Increased will be necessary. exposure of the proximal humerus by acromion osteotomy The deltoid muscle should be removed from the clavicle by raising an osteoperiosteal flap laterally to the acromion. In the three- and four-part configura- tions, an osteotomy of the acromion, which can be readily reattached with internal fixation, will allow wide access to the proximal humerus. In our opin- intramedullary devices. If greater access is required, ion, the advantage gained by this increased expo- the acromion may be osteotomized (Fig. 4.28a). This sure far outweighs the potential disadvantage of allows access to impacted four-part fractures, leaving the deltoid removal and its possible avulsion in the the shoulder capsule and blood supply to the head postoperative period. It will also allow the surgeon intact by operating through the fracture. to work with relative ease on the proximal fragment, The incision extends across the acromion and so that the vascular soft tissue attachments to that laterally over the deltoid muscle mass 4–5 cm. The fragment are not further damaged. deltoid fibers are split longitudinally (Fig. 4.28b). If necessary, the acromion is osteotomized (Fig. 4.28c), allowing greater access to the rotator Deltoid Muscle Splitting With or Without Acromion cuff and fracture. Distally, the deltoid split must be Osteotomy not more than 3–5 cm to avoid damage to the axil- lary nerve. This approach may suffice for limited access to the The acromion is usually restored by a tension band greater trochanter and some two-part fractures for wire, with or without screw fixation.

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b

a

Fig. 4.28a–c. Transacromial approach. The distal end of this approach is deltoid splitting, therefore it is of limited value only without an oste- otomy of the acromion. The incision is made across the acromion and to the mid-portion of the deltoid, but the deltoid split should not be performed further than 3 cm distal to the acromion because of the pres- ence of the axial nerve. If further exposure is needed the acromion is osteotomized as shown in the drawing (b). Insertion of a laminar spreader will allow visualization of the rotator cuff. In the four-part c impacted fracture in elderly patients, this will allow the surgeon to reduce the fracture without division of the capsule, and makes fi xation with a tension band fi gure-of-eight wire relatively easy (c)

4.4.3.3 not essential; therefore reduction should be obtained Reduction by applying traction, without disturbing the blood supply to the fragments. Once adequate reduction Once easy access has been obtained by reflecting the has been obtained, impaction of the fragments by deltoid, with or without a portion of the acromion, applying a blow to the elbow will restore some stabil- the fracture must be exposed through the disrupted ity to the fracture. Reduction of the head fragment soft tissues. No incisions should be made through should be performed atraumatically, especially if the intact soft tissues, no soft tissue should be removed fragment is small (see Fig. 4.12). The lesser tuberosity from any of the bony fragments, and only minimal will be found attached to the subscapularis and the dissection should be performed along the fracture rotator cuff to the greater tuberosity. Often, the two itself. In the upper humerus, anatomical reduction of are combined as a single fragment, with the long head the surgical neck and the comminuted fragments is of the biceps tendon running through it.

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If the head fragment in the four-part fracture In the two-part surgical neck fractures a stan- or fracture-dislocation is completely devoid of soft dard, laterally placed plate may be used if there is tissue, avascularity, of necessity, must be present; ample room for two screws proximal to the fracture therefore, a decision must be made to retain or dis- (Fig. 4.30; see also Fig. 4.7). In the three-part fracture, card this avascular humeral head, depending upon the plate may be supplemented by a tension-band the physiological age of the patient. wire, fixing the tuberosity fragments. Two 6.5-mm cancellous screws inserted well into the subchon- 4.4.3.4 dral area must be used to fix the proximal portion Methods of Internal Fixation of the plate. These screws should be fully threaded to increase their holding power. The use of the straight plate will obviate the need for a T plate placed across Good Bone the long head of biceps. If the obliquity of the surgical neck fracture allows, If the bone is of normal consistency and will hold a lag screw should be placed through the plate across a screw, the surgeon may proceed with standard the fracture line. This will greatly enhance the stabil- techniques of internal fixation, using lag screws and ity of the system (see Fig. 4.7). plates where required. In the three- and four-part fracture types, the T or L plates are the implants of choice (Fig. 4.31). If the Tuberosity Fractures. Fractures of the tuberosities T plate is chosen, the anterior limb of the T usually are true avulsion fractures; therefore, they require crosses the long head of biceps. This can be prevented dynamic compression techniques for stabilization, by the use of the L plate, which allows fixation of the either by tension band wiring or – in complex frac- proximal fragment with two large cancellous screws tures – by incorporation of the tuberosity fracture in into the proximal fragment and cortical screws into a tension band plate fixation. Occasionally, cancellous the shaft. The greater tuberosity should be incorpo- lag screws with washers may be used to achieve stable rated into the fixation device or, alternatively, may be fixation (Fig. 4.29). fixed with tension band wiring. Either the DC, the T, or the L plate may be applied Humeral Neck Fractures. The choice of implant will as a neutralization, buttress, or tension band plate. depend upon the fracture pattern. The implants avail- The various fracture types require different tech- able for the upper humerus are the T plate, the L niques: plate, standard 4.5-mm dynamic compression (DC) plates, blade plates, cancellous screws, both lag and 1. Transverse or short oblique fractures fully threaded, cortical screws, and finally cerclage – Surgical neck: since these unstable fractures wires. Locked IM nails can also be used for the correct occur in cancellous bone as a result of shear- indication, mainly in the displaced two-part surgical ing forces, ideally, the major fragments should neck fracture with intact tuberosities. be compressed. Transverse or short oblique fractures of the surgical neck are suitable for

a bc

Fig. 4.29. a Avulsion fracture of the greater tuberosity with subacromial impingement. b,c Reduction and internal fi xation with either cancellous screw (b) or a tension band wire (c). (From Müller et al. 1979)

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compression techniques using plates with 3. Articular Fractures. Displaced fractures of the lag screws across the fracture where possible articular surface of the humeral head (Fig. 4.19a) (Fig. 4.30). should be managed by open anatomical reduction – Anatomical Neck: oblique fractures through the and stable fixation (Fig. 4.19b–e). If the fracture anatomical neck may be compressed by using has been impacted, elevation of the fragments will large cancellous lag screws alone with washers create a gap that must be filled with cancellous or through a plate (Fig. 4.32). bone. Fixation of the joint fragments may be done 2. Comminuted or spiral fractures. Grossly commi- with lag screws or occasionally, if they are small, nuted or spiral fractures require provisional fixa- with Kirschner wires. Small avascular fragments tion with Kirschner wires supplanted by perma- should be discarded, as they will usually displace nent interfragmental screws. If the fragments are into the joint during rehabilitation and act as so small that a screw cannot be used, the Kirsch- loose bodies in the shoulder. ner wire should remain as part of the definitive fixation. The fracture must then be stabilized by a A large anterior or posterior glenoid rim fracture neutralization or buttress plate, care being taken affecting joint stability must be internally fixed. If the to incorporate the avulsed tuberosities, if present, fragment is large enough, it is best fixed with one or into the system. All soft tissue should be retained, two 4.0-mm cancellous lag screws. Occasionally, if the if possible. fragment is small, it may be fixed with a staple or with Kirschner wires. Care must be taken that the metal does not penetrate the articular surface – direct visu- alization of the joint surface is the best way to avoid this complication (see Fig. 4.20). In cases of complex two-, three-, and four-part frac- ture-dislocations, this glenoid rim fracture should be fixed last, after reconstruction of the other injuries.

Poor Bone

Viable Head; Cement Augmentation. Most surgeons Fig. 4.30. Oblique fracture of the surgi- develop a rather uneasy feeling during surgery if the cal neck fi xed with a six-hole dynamic compression (DC) plate. The two proxi- cancellous screws in the proximal fragment just keep mal screws are cancellous lag screws turning and turning and turning! If only one screw compressing the fracture is not holding but the remainder of the fixation is

a

b c

Fig. 4.31. a Reduction and fi xation of a fracture with a T plate. (From Muller et al. 1979). b,c Clinical example of a three-part fracture treated with an interfragmental screw and a long T plate

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Fig. 4.32a–d. Fixation of anatomical neck fractures. a Anatomical neck fractures may be fi xed with two screws using washers or through a plate used as a washer. These screws must be lag screws, as depicted. In osteoporotic bone, these screws may not hold and may pull out of the distal fi xation. b Anteroposterior radiograph of a four-part fracture of the proximal humerus in a 74-year-old woman. c,d The fi xation failed, as shown by the radiographs taken 4 months later. The patient’s end result was poor

a

b c d

good, then that screw should be removed, low-vis- and striking the elbow until impaction occurs. The cosity cement injected into the screw hole, and the shaft and head fragments should then move together screw replaced. This composite type of fixation may as one unit, which can be fixed with Kirschner wires reverse a difficult situation. If the entire purchase (Fig. 4.24c,d). Fine 1.6-mm or 2-mm Kirschner wires on the proximal fragment is poor, then low-viscos- are driven across the main fragments with a power ity cement should be injected into the fracture site drill; other fragments of bone are similarly fixed. The as well as into the proximal screw holes to ensure tuberosity fragments with the attached rotator cuff adequate fixation. We have also used this method in can also be provisionally fixed with Kirschner wires. other situations where excessive movement may be A large tension band wire is then inserted around expected in the postoperative period, for example, in the Kirschner wires in the tuberosities and inserted patients with severe tremor due to parkinsonism. On in the shaft, thereby imparting further stability to the rare occasion where the proximal fixation is good the fracture. Stability depends upon the degree of but the distal fixation poor, nuts may be used on the impaction achieved between the shaft and head cortical screws to enhance their fixation. fragments and upon the tension band wire. Usually, enough stability is obtained to allow early protected Impaction and Tension Band Techniques. If the sur- motion without fear of the fixation falling apart (see geon recognizes preoperatively that the bone is poor Fig. 4.25). Occasionally, cement may be used at the and that screws will not hold, a completely different fracture to ensure maintenance of the reduction and approach is indicated. Under these circumstances, to aid in stability. anatomical reduction is not attempted; stability is restored to the fracture by scooping out a portion of Percutaneous Techniques. For osteoporotic bone, the very soft bone in the proximal fragment with a many percutaneous techniques have been attempted, curet and impacting the humeral shaft into the hole especially Rush pins through the tuberosity into the so created (Fig. 4.24a,b). This impaction can be done shaft. This technique has given variable and incon- manually by placing the distal fragment into the hole sistent results and cannot be recommended except

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a b

Fig. 4.33a,b. Four-part fracture of the proximal humerus with the articular surface rotated 90° posterolateral, as noted in the radiograph a The fracture was fi xed with a percutaneous Rush pin. Unfortunately, the fracture was not reduced and healed with the humeral head facing laterally, causing major symptoms for the patient (b)

where the patient is in poor medical condition. The restoration of the tuberosity fragments containing pin tended to displace into the proximal fragment, the rotator cuff, will give satisfactory results (Neer allowing loss of reduction (Fig. 4.33). However, Rob- 1955). We feel that a four-part fracture or fracture- inson and Christie (1993) compared this technique dislocation in an older patient with a totally avascular with open reduction and internal fixation (ORIF) crescentic head fragment, devoid of all soft tissue, is (AO) in older osteoporotic patients and found the the only indication for primary prosthetic replace- results to be more favorable. Retrograde pins have ment of the humeral head. The results of this proce- also been used (Zifko et al. 1991) with reasonable dure, if strict attention to technical detail is followed, results in these difficult patients. are good (Hawkins and Switlyk 1993). However, many Other techniques of percutaneous pinning are reports to the contrary make this a controversial issue described, and may lead to satisfactory results. (Zingg at this time. In younger patients with a nonviable et al. 2002). A knowledge of the safe area of placement humeral head, shoulder arthrodesis may be indicated is essential, to avoid injury to nerve and blood vessels (Fig. 4.35). This should rarely be done as a primary (Rowles and McGrory 2001) procedure, since avascular necrosis of the humeral head may be tolerated by the patient. Alternative Internal Fixation Devices. The new con- cept of the locking plate, “fixateur interne,” is a major 4.4.3.5 advance in the fixation of fractures through osteopo- Wound Closure rotic bone (Fig. 4.34) As well, locked IM nails may be used for surgical neck two-part fractures patterns, but The deltoid muscle should be reattached with non- are rarely indicated for three- and four-part fractures. absorbable sutures through the attached osteoperios- Nonviable Head. In a four-part fracture or fracture- teal flaps into the clavicle. If the acromion has been dislocation through osteoporotic bone, the head frag- osteotomized, nonabsorbable sutures or wire may be ment is usually free and avascular. Often, the bone used to reattach it. Occasionally, a screw through a is so soft that fixation is impossible. Even if fixation predrilled hole may be inserted. The deltoid muscle were possible, avascular necrosis would certainly will then cover the entire fracture complex and the ensue, compromising the final result. Under these implant. The skin should be closed primarily over circumstances, especially in elderly individuals, we suction drains. If the fracture was open, that portion suggest a unipolar prosthetic replacement (Fig. 4.26). of the skin previously open should be left so and Precise attention to detail, including the correct ret- can be dealt with by closure on the fifth day, if clean roverted position of the prosthetic head and careful granulation has appeared.

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a b c d

Fig. 4.34. a Specialized 3.5-mm specialized locking plate for the proximal humerus (internal fi x- ator). b Four-part fracture fi xed with locking plate and screws (c,d)

4.4.3.6 idly regain full shoulder motion, often to a surprising Postoperative Care degree within the first 2 weeks following surgery. If there is concern about the deltoid suture, an abduc- Early tion splint is applied, the patient being allowed out of the splint for pendulum exercises only. In these The early postoperative care will depend upon the circumstances we do not allow active deltoid contrac- surgeon’s assessment of the degree of stability pres- tion against resistance until biological healing of the ent. In the immediate postoperative period, we prefer deltoid muscle insertion has occurred, usually within to immobilize the patient in abduction, either with 4–6 weeks. the use of pillows or with skin traction. If the stability If the stability of the fracture is in question, the of the fracture is sound, the patient may be taken out surgeon must use his or her own judgment as to the of the abducted position on the second postoperative best method and timing of the rehabilitation process. day and allowed pendulum exercises. Active contrac- Pendulum exercises without resistance can usually be tions of the deltoid muscle are encouraged if there is carried out with any stable internal fixation, but if the no concern about the deltoid resuture. Young patients bone is so poor that the fixation is in jeopardy, the with anatomical reduction and rigid fixation will rap- patient should be immobilized in an abduction splint

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a b c

Fig. 4.35. a Avascular necrosis of a small crescentic head fragment following fracture-disclocation. b Seven months later, the fracture had healed, but the humeral head had collapsed. c Management of this 22-year-old man was by arthrodesis

until some sign of bone union is noted, usually by the proximal humerus fractures using the screw-tension band sixth week. techniques. J Ortho Trauma 8/1:23–27 If a prosthetic replacement has been used, the Court-Brown CM, Cattermole H, McQueen MM (2002) Impacted valgus fractures (B1.1) of the proximal humerus. patient is immobilized in abduction in the immedi- The results of non-operative treatment. J Bone Joint Surg ate postoperative period and the abduction splint is BR, May; 84(4): 504–8 used for 4–6 weeks; pendulum and resisted deltoid Demirhan M, Kilicoglu O, Altinel et al (2003) Prognostic fac- exercises are allowed during this period. tors in prosthetic replacement for acute proximal humerus fractures. J Orthop Trauma Mar; 17(3): 181–8 Esser RD (1994) Treatment of three and four-part fractures of Late the proximal humerus with a modified cloverleaf plate. J Ortho Trauma 8/1:15–22 The patient should be followed up carefully for clini- Flatow EL, Cuomo F, Maday M et al (1991) Open reduction cal and radiological signs of implant failure, such and internal fixation of two-part displaced fractures of the as lucency around the screws, loss of plate fixation, greater tuberosity of the proximal part of the humerus. J Bone Joint Surg 73A/8 or movement at the fracture site. If any of these are Goldman RT, Koval KJ, Cuomo F et al (1995) Functional out- noticed, it is far better to immobilize the patient in come after humeral head replacement for acute three and an abduction splint until union has occurred than to four part proximal humeral fractures. J Shoulder Elbow persist with early motion, which may result in total Surg Mar-Apr, 4 (2) ; 81–6 loss of the fixation. Reoperation would be more haz- Hawkins RJ, Switlyk P (1993) Acute prosthetic replacement for severe fractures of the proximal humerus. Clin Ortho Relat ardous, because the already porotic bone would be Res 289:156–160 even worse a few weeks after the injury. Henry AK (1927) Exposure of the long bones and other surgi- cal methods. Wright, Bristol Jaberg H, Warner J, Jakob RP (1992) Percutaneous stabiliza- tion of unstable fractures of the humerus. J Bone Joint Surg 74A/4 Jakob RP, Miniaci A, Anson PS et al (1991) Four-part valgus References impacted fractures of the proximal humerus. J Bone Joint Surt 73B/2 Bosch U, Skutek M, Fremerey RW, Tscherne H (1998) Outcome Kocialkowski A, Wallace WA (1990) Closed percutaneous K- after primary and secondary hemiarthroplasty in elderly wire stabilization for displaced fractures of the surgical patients with fractures of the proximal humerus. J Shoul- neck of the humerus. Injury 21:209–212 der Elbow Surg Sep-Oct; 7 (5); 479–84 Koval KJ, Gallagher MA, Marsicano JG et al, (1997) Functional Brorson S, Bagger J, Sylvest A et al (2003) Improved interob- outcome after minimally displaced fractures of the proxi- server variation after training of doctors in the Neer mal part of the humerus. J Bone Joint Surg AM Feb; 79 system. J Bone Joint Surg Br 84(7): 950–4 (2): 203–7 Burstein AH (1993) Fracture classification systems: do they McLaughlin HL (1960) Recurrent anterior dislocated shoulder. work and are they useful? J Bone Joint Surg 75A/12:1743 Morbid anatomy. Am J Surg 99:628–632 Codman EA (1934) The shoulder. Rupture of the supraspina- Moeckel BH, Dines DM, Warren RJ et al (1992) Modular tus tendon and other lesions in or about the subacromial hemiarthroplasty for fractures of the proximal part of the bursa. Todd, Boston humerus. J Bone Joint Surg 74A/6 Cornell CN, Levine D, Pagnani MJ (1994) Internal fixation of Müller ME, Allgöwer M, Willenegger H (1979) Manual of

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internal fixation, 2nd edn. Springer, Berlin Heidelberg New proximal part of the humerus. An anatomic study. J Bone Yo r k Joint Surg AM Nov; 83-A (11): 1695–9 Müller ME, Allgöwer M, Schneider R, Willenegger H (1991) Sidor ML, Zucherman JD, Lyon T et al (1993) The Neer clas- Manual of internal fixation, 3 rd edn. Springer, Berlin Hei- sification system for proximal humeral fractures. J Bone delberg New York Joint Surg 75A/12 Neer CS (1955) Articular replacement for the humeral head. J Siebenrock K, Gerber C (1993) The reproducibility of classi- Bone Joint Surg 37A:215–228 fication of fractures of the proximal end of the humerus. J Neer CS (1970) Displaced proximal humeral fractures. I. Classi- Bone Joint Surg 75A/12 fication and evaluation. J Bone Joint Surg 52A: 1077–1089 Szyszkowitz R, Schippinger G (1999) Fractures of the proximal Nicoll E (1964) Fractures of the tibial shaft. A survey of 105 humerus. Unfallchirurg 6:422–428 cases. J Bone Joint Surg [Br] 46B:313–381 Szyszkowitz R, Seggl W, Schleifer P, Cundy P (1993) Proximal Rasmussen IH, Dalsgaard J, Christensen BS, Holstad E (1992) humeral fractures. Management techniques and expected Displaced proximal fractures: results of conservative treat- results. Clin Orth Relat Res 292:13–25 ment. Injury 23/1:41–43 Tamai K, Hamada J, Ohno W, Saotome K (2002) Surgical Robinson CM, Christie J (1993) The two-part proximal anatomy of multipart fractures of the proximal humerus. J humeral fracture: a review of operative treatment using Shoulder Elbow Surg Sep-Oct; 11(5): 421–7 two techniques. Injury 24/2:123–125 Zingg U, Brunnschweiler D, Keller H, Metzger U (2002) Percu- Robinson CM, Royds M, AbrahamA, McQueen MM, Court- taneous minimal osteosynthesis of fractures of the proxi- Brown CM, Chrstie J (2002) Refractures in patients at mal humerus in elderly patients. Swiss Surg ; 8 (1): 11–4 least forty-five years old: a prospective analysis of 22,060 Zifko B, Poigenfurst J, Pezzei C, Stockley I (1991) Flexible patients. J Bone Joint Surg AM 9:1528–1533 intramedullary pins in the treatment of unstable proximal Rowles DJ, McGrory JE ( 2001) Percutaneous pinning of the humeral fractures. Butterworth-Heinemann, London

4.1 Introduction

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